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Psych Unit 1 > 5 Peds Psych, ADHD, & Psychopharm Review > Flashcards

5 Peds Psych, ADHD, & Psychopharm Review Flashcards

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1
Q

ADHD is a persistent pattern of ________ and/or _____________ that is more frequently displayed and more severe than is typically observed in individuals at a ____________ of development.

A

Inattention and/or hyperactivity-impulsivity

Comparable level

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2
Q

DSM-5 diagnostic criteria for ADHD

A

A. Persistent pattern of inattention and/or hyperactivity-impulsivity that INTERFERES with functioning or development, as characterized by (1) and/or (2)

  1. 6 or more Inattention symptoms for at least 6 months, inconsistent with developmental level and negatively impacts on social and academic/occupational activities
  2. 6 or more Hyperactivity-Impulsivity symptoms for at least 6 months, inconsistent with developmental level and negatively impacts on social and academic/occupational activities

B. Symptoms present prior to age 12
C. Symptoms present in 2 or more settings
D. Clear evidence symptoms interfere with, or reduce quality of, social, academic, or occupational functioning

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3
Q

To meet DSM-5 criteria for ADHD you need 6 or more of these inattention symptoms…

A 
Careless mistakes due to inattention
Difficulty sustaining attention
Does not listen when spoken to directly
Does not follow through or finish work
Difficulty organizing tasks
Avoids tasks that require sustained mental effort
Loses things necessary for tasks
Easily distracted by extraneous stimuli
Forgetful in daily activities
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4
Q

To meet DSM-5 criteria for ADHD you need 6 or more of these hyperactivity-impulsivity symptoms…

A

Fidgets
Leaves seat when sitting in seat is expected
Runs/climbs excessively in inappropriate situations
Difficulty playing/engaging in leisurely activities quietly
“On the go”
Talks excessively
Blurts out answers prematurely
Difficulty awaiting turn
Interrupts or intrudes others

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5
Q

Specifiers for ADHD diagnosis

A

Specify whether Combined Type, Predominantly Inattention Type, or Predominantly Hyperactive-Impulsive Type

Specify whether in partial remission (<6 Sx for 6 months or more after previous full diagnosis)

Specify current severity (Mild, Moderate, or Severe)

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6
Q

Prevalence of ADHD

A

5% of children
2.5% of adults
M:F = 2-4:1

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7
Q

ADHD is difficult to diagnose in younger children (<5) due to…

A

Age-appropriate behaviors in active children (DON’T give them meds)

Also, parents can be unreliable historians

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8
Q

ADHD is most common in ________ children

A

Elementary school-aged

Make sure to obtain info from TEACHERS (parents often unreliable historians)

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9
Q

What two things should you keep in mind when diagnosing ADHD in adulthood?

A

If comorbid with SUD, Mood Disorder, or Anti-Social Personality, increased risk of SUICIDE

For new diagnoses, use caution with basing diagnosis on patient’s childhood recall of ADHD (OBTAIN SCHOOL RECORDS)

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10
Q

Some DDx for ADHD that can co-occur with the condition

A 
Age-appropriate behaviors in active children
LEARNING DISORDER
Depression/Bipolar disorder
Anxiety
Post-traumatic stress disorder
Stereotypic movement disorder
OPPOSITIONAL DEFIANCE DISORDER
CONDUCT DISORDER
SUBSTANCE ABUSE
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11
Q

Environmental factors that may contribute to ADHD

A

Stressful home
Inappropriate schools
Under-stimulated environments

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12
Q

Medical conditions that may confound Dx of ADHD

A 
HEARING/VISUAL IMPAIRMENTS***
Lead poisoning
Asthma
FAS
Thyroid abnormalities
Sleep disorders
Seizures
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13
Q

A comprehensive medical, developmental, educational, and psychosocial evaluation is done for patients suspected of having ADHD, in order to…

A

Confirm symptoms

Demonstrate functional complications

Exclude other explanations for symptoms

Identify comorbid psychiatric conditions

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14
Q

Other evaluation tips for ADHD

A

Eval may be done in primary care

Review of medical, social, and family histories should be included

Interview both patient and parents

Collect info from other caregivers and TEACHERS

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15
Q

What do we need to know about rating scales for ADHD?

A

There are several scales but Dx still REQUIRES validation with DSM-5

Pediatric scales:
• Vanderbilt Assessment Scale (primary care and in referral for 4+ yo)
• Conners Comprehensive Behavior Rating Scales (ok for preschool)
• ADHD Rating Scale IV (preschool ok)

Adult:
• ASRS (ADHD Self Report Scale)
• CAARS (Conners Adult ADHD Rating Scale)

CAARS should be completed at time of Dx, during med titration, and at regular medication follow-up visits

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16
Q

What sorts of questions should you ask of parents?

A

How is your child doing in school?

Have you or the teacher noticed any problems with learning?

Is your child happy in school?

Does your child have any behavioral problems at school or home or when playing with friends?

Does your child have problems completing school assignments at school or home?

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17
Q

What questions should you ask of teachers?

A

How is the child’s behavior in school?

What interventions does the child require?

What are the child’s learning patterns?

Is there functional impairment?

How does the child get along with others?

How is the child’s work?

How are the child’s grades?

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18
Q

What is the pathophysiology of ADHD?

A
  1. Environmental factors
    Pre-, peri-, and post-natal complications
    Childhood diseases
    Trauma, toxins, drug exposures
  2. Neurotransmitter alterations
    Decreased dopamine and/or NE availability in cortex
  3. Neuroanatomical changes in circuits
    Pre-frontal cortex, parietal cortex, striatum, and cerebellum
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19
Q

What neurotransmitters are produced by the RAS?

A

NE
Serotonin
Dopamine
Acetylcholine

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20
Q

The targets for NTs produced by the RAS are …

A

Discrete nuclei within the basal forebrain, limbic system, and cerebral cortex

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21
Q

Where is Norepinephrine produced?

A

Locus Coeruleus (LC) - a part of RAS

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22
Q

Norepinephrine targets Cortex, Hypothalamus, and Brainstem for…

A

Arousal and sleep/wake cycles

Consciousness

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23
Q

Norepinephrine targets Cortex for regulating…

A

Attention

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24
Q

Norepinephrine targets Cortex and Limbic System for regulating…

A

Mood

Learning and Memory

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25
Q

What are the two classes of receptors for NE?

A

Alpha

Beta

There are multiple subclasses of each

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26
Q

Disorders associated with NE imbalance

A

ADHD - due to underactive cortical inhibition

Mood disorders - esp Bipolar states

Anxiety Disorders - generalized anxiety and PTSD

Drugs of Abuse - psychostimulants

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27
Q

Serotonin (5HT) is produced in…

A

The Raphe Nuclei (dorsal) of the brainstem

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28
Q

Limbic system targets of Serotonin regulate…

A

Mood

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29
Q

Cortex and thalamus targets of Serotonin regulate…

A

Sensation/Perception

30
Q

Hypothalamus targets of Serotonin regulate…

A

Circadian rhythms

Appetite

31
Q

Disorders associated with Serotonin imbalance

A

Mood disorders (5HT modulates NE)

Impulse Control Disorders

Obsessive-Compulsive Disorders

Anxiety Disorders (social anxiety and generalized anxiety)

Eating Disorders

Drugs of Abuse (Hallucinogens)

32
Q

Dopamine is produced in …

A

Substantia Nigra (SN)

Central Tegmental Area (VTA)

33
Q

DA produced in the substantia nigra targets _______ for ________

A

Basal Nuclei

Motor control

34
Q

DA produced in the VTA targets _______ for ________

A

Limbic System and Cortex

Reward, reinforcement, and cognition

35
Q

What cells are attacked in Parkinson’s disease?

A

Substantia Nigra

This leads to a loss of dopamine to the basal nuclei —> loss of motor control

36
Q

Disorders associated with DA imbalance

A

Psychotic disorders (dysregulation of VTA to cortex/limbic pathways)

Substance use disorders (euphoria due to substances activating VTA/NAc pathway)

Movement disorders (Parkinson’s due to low DA in striatum/basal nuclei)

Cognitive disorders (Delirium)

Mood disorders (only moderate association)

37
Q

Acetylcholine is produced in …

A

Medial Septum (MS)

Nucleus Basalis of Meyers (nBM)

(Both are in the basal forebrain)

38
Q

Acetylcholine produced in MS targets ______ for _______

A

Hippocampus

Learning/memory

39
Q

Acetylcholine produced in nBM targets ______ for _______

A

Cortex

Attention

40
Q

Acetylcholine imbalance is associated with…

A

Dementia

Neurocognitive disorders

41
Q

Where is glutamate produced?

A

Throughout the CNS

Targets are both local and distributed

42
Q

What is the primary excitatory NT in the CNS?

A

Glutamate

43
Q

Disorders associated with glutamate imbalance

A

Psychotic disorders

Bipolar disorders

Substance abuse disorders

Dementia
• Alzheimer’s Disease
• A glutamate receptor (NMDA) hypersensitive to stimulation in AD (blocked by Memantine)

44
Q

Where is GABA produced?

A

Throughout the CNS

45
Q

What is the most ubiquitous NT in the brain?

A

GABA - the primary inhibitory neurotransmitter in the CNS

Targets are local neurons

46
Q

What happens if you take GABA away?

A

Seizures

That’s why you can’t go cold turkey from alcohol, benzos, barbiturates, etc

47
Q

Disorders associated with GABA imbalance

A

Seizure disorders (normal brain is topically under GABA inhibition)

Mood disorders - mood stabilizers are GABA drugs

Bipolar disorders

Drugs of abuse - all depressants are GABA agonists

Anxiety disorders - can be treated with GABA agonists

48
Q

Anticonvulsants are ______ agonists

A

GABA

B/c brain is normally under tonic GABA inhibition

49
Q

Why does titrations medications to treat psychiatric disorders take patient/provider trial and error?

A

B/c variation from one patient’s brain to the next (different concentrations of receptors)

50
Q

How does presynaptic modulation of NTs work?

A

NT Release

NT Reuptake

51
Q

How does synaptic modulation of NTs work?

A

NT breakdown by enzymes

52
Q

How does postsynaptic modulation of NTs work?

A

Receptor binding (agonist or antagonist)

Signal transduction

Genomic alterations

53
Q

What are the five components of ADHD treatment?

A

Psychotherapy (most important for adults)

Behavioral modifications (train that frontal lobe)

Educational intervention

Environmental manipulation (esp in kids)

Pharmacotherapy

54
Q

How do you treat preschool children (age 4-5) for ADHD?

A

BEHAVIOR THERAPY as initial therapy

Meds only if needed (METHYLPHENIDATE)

55
Q

How do you treat school-aged children (≥6) and adolescents for ADHD?

A

MEDS (rather than behavior therapy alone or no intervention) - esp Ritalin

Behavioral interventions added to med therapy

56
Q

What is important to monitor when medicating children for ADHD?

A

Monitor Sx and medication effects

Monitor Rx records!

57
Q

Are diets recommended for ADHD

A

No.

Doesn’t mean they won’t be helpful, just that there aren’t any endorsed diets b/c no data that they are helpful

58
Q

How do you treat ADHD in adults?

A

Medication (amphetamine salts)

Atomoxetine (or bupropion) if substance abuse is concern (utilize drug screening)

Antidepressants

CBT as adjunct

59
Q

What sorts of behavior mods should you incorporate when treating ADHD?

A

Maintain daily schedule
Keep distractions to a minimum
Provide specific and logical places to keep schoolwork, toys, and clothes
Set small, reachable goals
Reward positive behavior
Use charts and checklists to stay “on task”
Limit choices
Find activities in which the child can be successful
Use calm discipline (time out, distraction, remove from situation)

60
Q

What sorts of educational intervention is needed in children with ADHD?

A 
Tutoring
Individualized Education Programs (IEPs)
Write assignments on board
Smaller class size
Sit near teacher
Frequent breaks
Extra time to complete tasks/tests
Signal from the teacher when he/she is “off-task”
Daily reports to parents
61
Q

How do stimulants work to treat ADHD?

A

Increase the release of dopamine and NE

Methylphenidate (Ritalin, etc) and Dextroamphetamine (Dexedrine, Vyvanse) are most commonly used

Can also use mixed amphetamine salts (Adderall)

All are controlled substances

62
Q

Short-acting formulations of stimulants for ADHD must be taken _______ while long-acting formulations can be dosed ______.

A 
Short-acting = BID-TID
Long-acting = QD (but side effects can extend longer)

Down side of long-acting = more expensive

63
Q

How are outcomes quantified in treatment of ADHD?

A

Symptom severity (utilize conners scales, ADHD-RS, ASRS, CAARS)

Treatment retention

Adverse events

64
Q

Most common adverse effect of stimulants used to treat ADHD

A

Decreased appetite

65
Q

Side effects of stimulants used to treat ADHD

A 
Appetite disturbance —> weight loss
Social withdrawal, personality changes
Irritability
Nervousness
Sleep disturbance
HA, stomach pain
Tics
Contact dermatitis (if using patch)
Increased HR/BP
Sudden cardiac death if underlying cardiac disease
66
Q

Why do you need to do a cardio workup when prescribing stimulants for ADHD?

A

If risk factors for CVD, b/c increased risk of sudden cardiac death if underlying cardiac disease

67
Q

What do we need to know about Atomoxetine (Strattera)?

A

Selective NE reuptake inhibitor

Not a controlled substance

Less potential for abuse

More expensive than methylphenidate and dextroamphetamine

May not be as effective for some patients

68
Q

Side effects of atomoxetine

A 
Weight loss
Abdominal pain
Decreased appetite 
N/V
Dyspepsia
Sleep disturbances
Tics
Severe liver injury
Increased suicidal thinking 
Cardiac risk
69
Q

_______ are always first-line for ADHD in any patient ≥6 years

A

Stimulants

70
Q

_________ is a better option for a patient with hx of substance abuse

A

Atomoxetine (Strattera)

Psych Unit 1 (6 decks)

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